burns: evaluation and treatment provider disclaimer
TRANSCRIPT
1
Burns: Evaluation and
Treatment
Jennifer Gardner, PT DPT MHA CWS
Provider Disclaimer
• Allied Health Education and the presenter of
this webinar do not have any financial or other
associations with the manufacturers of any
products or suppliers of commercial services
that may be discussed or displayed in this
presentation.
• There was no commercial support for this
presentation.
• The views expressed in this presentation are
the views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Objectives
1) List and describe types and severity of burns
2) Identify classification systems for determining
burn size
3) Identify basic treatment options for burns,
including medical treatment as well as the
physical therapist’s role
4) Describe what hypertrophic scarring is and why it
occurs
5) List psychosocial aspects of caring for burn
patients
2
Definition of Thermal
Injuries/Burns
• An acute wound caused by exposure
to thermal extremes, caustic
chemicals, electricity or radiation
• The degrees of tissue damage
depends on the strength of the
source and duration of contact or
exposure
• High morbidity and mortality rate
Burns
• Skin no longer provides barrier
and allows body heat and water to escape and bacteria to enter
• Loss of sensation, sweating,
sebum secretion and skin elasticity occur
• Large amount of fluid loss
Risk Factors and
Populations
• Everyone is at risk for burns; however,
most are not severe
• Estimated over a million burn injuries per year. Of these, 486,000 require medical
attention and 40,000 require
hospitalization
• 3,275 deaths from fire/smoke inhalation
• Kitchen spills, contact injuries, electric
burns, and occupational hazards account
for majority of burns
American Burn Association, 2016
3
Thermal Burns
• Most common type of burn • Scalds: Hot liquids
• Typically seen in children who pull a hot pan off the stove or in abuse situations
• Flame: Typically see inhalation damage with this type
• Contact: Heating pad, radiator
• Results from any misuse or mishandling of fire or a combustible product.
• Frostbite is also a thermal burn obviously caused by extreme cold
Thermal burns
Frostbite
4
Electrical • Results from contact with flowing electrical
current, i.e. household current, high-voltage transmission lines and lightning
• Minimal external damage noted but significant
internal injury can occur • Can affect all internal organs/functions
− Cardiovascular: Cause an arrhythmia or cardiac arrest; Aneurysm, tissue ischemia; Will need close monitoring
− Respiratory: Cause respiratory arrest
− Neurological: Loss of consciousness, neuropathy, spinal cord injury
− Musculoskeletal: Fractures, dislocations, compartment syndrome
− Kidney: Renal failure if extensive muscle necrosis
• Commonly see an entrance and an exit wound http://www.dermnetnz.org/topics/electrical-burns/
Electrical
Electrical
5
Chemical
• Most commonly results from contact(skin contact or inhalation) with a caustic agent
• Usually deep as it continues to burn tissues until it is completely removed or washed away
• May need to remove clothes and shower patient
• Sometimes evidence of abuse with attacker
throwing caustic agents at victim
• Alkaline chemicals tend to burn more than
acidic ones • Example of alkaline chemical is cement
Chemical
Radiation
• Sunburn
• Result of radiation treatment or
radioactive material exposure
• Often called radiation dermatitis
6
Injuries
Radiation
Classification and
Characteristics of Burn
• Classified by level of tissue
involvement and amount of surface area affected
• Determine size
• Determine depth
• Determine severity
• All of these may take 3-4 days to fully
assess given evolution of wound and
presence of eschar
Determine the size
• Small, superficial burns are measured like any other wound • Length x width x depth
• Larger burns are expressed as a percentage of total body surface area(BSA) • Several classification systems are used
7
Three classification
systems • Lund & Browder
• Used more frequently for children and infants because the Rule of Nine’s is inaccurate for their body shapes and hence, their BSA
• Classification changes based on age of child
• Rule of Nine’s • Quantifies BSA in multiples of 9’s
− Anterior Body: Each leg is 9%, trunk is 18%, each arm is 4.5%, head is 4.5% and genital area is 1%
− Posterior Body: Each leg is 9%, trunk is 18%, each arm is 4.5% and head is 4.5%
− Totaling 100%
• Palmar Method: • Uses palm of hand to determine burn size
health.yahoo.com
Rule of Nine’s
Lund and Browder
Charts www.biotel.ws
8
Palmar Method
Depth of Burn
Injuries • Can define by thickness
• Partial thickness burn involves epidermis and part of dermis
• Full thickness burn Involves epidermis, dermis and
subcutaneous tissue
• Can also define by degree • First
• Second
• Third
• Damage usually involves several depths and degrees
• Consider viewing Burns 101 Assessment for more info
https://www.youtube.com/watch?v=DbE0iCq25Z4
Superficial/1st
Degree
• Damage is limited to epidermis, causing
erythema and pain
• Skin will peel in several days
• No treatment necessary typically
• Sun burn or minor flash burn
9
Superficial/1st
Degree Burn
www.nlm.nih.go
Superficial/1st
Degree Burn
homeemergency.wordpress.com
Superficial Partial-
Thickness/2nd Degree
• The epidermis and part of the dermis are
damaged
• Produces blisters, mild-to-moderate edema
and pain
• Healing occurs within 2 weeks
• No scar
10
Superficial Partial-
Thickness/2nd
Degree Burn
www.nlm.nih.go
Superficial Partial
Thickness/2nd
Degree Burn
www.islamicmedicine.
org
Schraga et al, Emergent Management of Thermal Burns.
2nd Degree Burn
11
Deep Partial Thickness
• The epidermis and dermis are damaged
• No blisters appear but white, brown or
black leathery tissue and thrombosed
vessels are visible
• Leaves hair follicles and dermal
appendages intact so epidermal cells can
be produced
Full-Thickness/3rd
Degree
• Damage extends through deeply
charred subcutaneous tissue to muscle and bone
• No pain
• Heals like a full thickness wound with granulation,
epithelialization and wound contraction
Full Thickness/3rd
Degree Burn
health.yahoo.com
12
Full-Thickness/3rd
Degree Burn
www.roanoke.k12.va.us
Schraga et al, Emergent Management of Thermal Burns.
Subdermal
• Destruction beyond dermis and into fat,
muscle, tendon and/or bone. Typically due
to electrical injuries, prolonged thermal
contact or exposure to strong injuries
Full Thickness/3rd
Degree
13
Subdermal
Determining the
Severity • Severity of a burn is determined by both its size and depth
• Major: Meets 1 or more of these criteria
• 3rd degree burns on more than 10% of BSA
• 2nd degree burns on more than 25% of BSA in adults; more than 20% in children
• Burns on the hands, face, feet or genitalia
• Electrical burns
• Any burn in a high-risk patient
• Moderate: Meets 1 or more of these criteria
• 3rd degree burns on 2-10% of BSA
• 2nd degree burns on 15-25% of BSA in adults, 10-20% of BSA in children
• Minor: Meets 1 or more of these criteria
• 3rd degree burns on less than 2% of BSA
• 2nd degree burns on less than 15% of BSA in adults, less than 10% of BSA in children
Initial assessment of
Burn Patient (ABCDE)
• Airway: Assess airway and remove any obstruction
• Breathing: Observe patient’s breathing rate, depth and character
• Circulation: Palpate pulses; Loss of distal pulse may indicate shock or constriction of an extremity
• Disability: Assess patient’s level of consciousness and ability to function
• Expose: Remove burned clothing and
examine the skin underneath.
14
Airway management
• 3 types of inhalation injuries:
• Patients with carbon monoxide poisoning
• Upper airway thermal burns
• Inhalation of combustible materials
• It is very important to maintain airway and
this will be done with intubation
• May combine with percussion, prone positioning,
use of steroids
Acute Changes
• Physiologic:
• Fluid volume: Input via IV fluids greater
than output as edema increases
• Body weight: Need accurate dry weight
to measure amount of resuscitation
• Body temperature: May be elevated
• Electrocardiographic status: May see
dysrhythmias
Acute Changes
• Biochemical and Hematologic: • Serum creatinine and blood urea nitrogen: Ensure
kidney function is normal
• Hemocrit & Hemoglobin: May decrease after surgical
interventions
• White Blood Cell Count: May increase or decrease
depending on amount of fluid resuscitation
• Blood glucose: May see hyperglycemia
• Electrolytes: Imbalance can be avoided with lactated
Ringer’s
• Plasma protein and myoglobin levels: May see
elevated myoglobin levels
• Prothrombin time, partial thromboplastin time and
platelet count: Expect to be normal except in patients
with preexisting disease
15
Special Assessment Considerations • Pay particular attention to these factors
that affect healing and treatment: • Burn location: Burns on face, hands, feet and
genitalia are most serious due to possible loss of function
• Burn configuration: Edema due to circumferential burn can slow or stop circulation to extremity; Burns on neck can obstruct airway; Burns on chest can interfere with normal respiration
• Pre-existing conditions
• Other injuries sustained at time of burn • Patient age: Patients under 4 or over 60 are at
higher risk of complications
• Pulmonary injury: Inhaled smoke or super-heated air damages lung tissue
Burn Interventions
• Care of burns depends on type and
severity of burn, the patient’s general health prior to injury, and whether there are concurrent injuries
• In general, treatment seeks to:
• Reduce pain
• Remove dirt, debris and dead tissue
• Provide a dressing that promotes healing and possible skin grafting
• American Burn Association has developed criteria for when to transfer to burn center
When to refer to a
Burn Unit
• Any partial-thickness burn larger than 20% of
total body surface area (TBSA) in a patient of
any age or larger than 10% of TBSA in
children younger than 10 years or adults older
than 50 years
• Third-degree burns covering more than 5% of
TBSA
• Second-degree or third-degree burns involving
critical areas (e.g., hands, feet, face,
perineum, genitalia, or major joints)
• Burns with associated inhalation injury Schraga et al, Emergent Management of Thermal Burns.
16
When to refer to a Burn Unit
• Electrical or lightning burns
• Severe burns complicated by coexisting
trauma - If traumatic injuries pose a higher
risk to the patient than the burn injuries, the
patient may have to be sent first to a trauma
center
• Preexisting disease that could complicate
management of the burn injury
• Chemical burns with threat of cosmetic or
functional compromise
• Circumferential burns on the extremities or
the chest Schraga et al, Emergent Management of Thermal Burns.
Criteria for Outpatient
Management of Burn
Patients
• Appropriate
• Patients with small burns who
have demonstrated understanding
of wound care, pain control and
therapy
-Mosier & Gibran, 2010
Criteria for Outpatient
Management of Burn
Patients • Inappropriate: These patients
need special care and consideration • Abused patients
• Even signs of self-induced injury
• Demented patients
• Intoxicated patients
• Homeless patients
• Patients with comorbid conditions
• Patients with a language barrier
-Mosier & Gibran, 2010
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Minor to Moderate Burns
• 1st step is to stop the burning process and relieve pain
• Never use hydrogen peroxide or povidone-iodine because they can cause further tissue damage
• After devitalized tissue is debrided, cover wound with antimicrobial ointment and non-
adhesive dressing
Moderate to Major Burns
• Same initial treatment as with mild to moderate burns
• Also begin IV therapy to replace lost fluids, so as to prevent hypovolemic shock and help maintain cardiac output
• Careful monitoring of input and output is needed
Medical Management
• Intravenous lines to replace
fluid lost
• Nutritional support
• Elevate room temperature
• May require intubation
18
Debridement and Cleansing
• May involve whirlpool
• Also includes sharp debridement that can be done
by PTs
• Can also include use of a contact ultrasound such
as Sonic One by Misonix or Arobella Qoustic system
• Debate over whether intact blisters should be left
alone or ruptured; However, widely accepted that
ruptured blisters and necrotic tissue should be
removed
• Current World Health Organization recommendation is to
“debridement of all bullae and excision of all adherent
necrotic tissue” (Jenkins, 2013)
• https://www.youtube.com/watch?v=FPc1B6EaKug
Debridement and
Cleansing
https://www.youtube.com/watch?v
=L85PERCCi0c
19
Debridement and Cleansing
• May need surgical debridement
• Circumferential full-thickness burns involving
the chest or extremities may require
escharotomy
• The necrotic tissue, or eschar, becomes rigid
and acts like a tourniquet
• Escharotomy is done via a linear and lengthwise
incision
• This “allows return of [blood] flow and
prevents further ischemic injury” (Jenkins,
2013)
Escharotomy
Example of escharotomy:
https://www.youtube.com/watch?v=G6DGBO24njQ
Debridement and
Cleansing
• Several misconceptions in regards to
cleansing of burns
• Must use sterile saline
• Burns must be scrubbed to debride
superficial exudate
• Instead burns can be washed with regular
non-scented soap and tap water during
daily shower or bath and can be simply
wiped with a soapy washcloth to help
remove any topical agents and exudate
19
Mosier & Girban, 2010
20
Skin Grafting • May be necessary to repair defects
caused by burns
• May be from patient’s own intact
skin or from cadavers or pigs or from
skin equivalents
• Surgeon may choose skin grafting if:
• Primary closure is not possible or
cosmetically acceptable
• Primary closure would interfere with
function
• Wound is on a weight-bearing surface of
the body
Skin grafting
• 3 types
• Split-thickness grafts: Consist of
epidermis and a small portion of the
dermis
• Full-thickness grafts: Include the
epidermis and all of the dermis
• Composite grafts include epidermis,
dermis and underlying tissues such as
muscle, bone or cartilage
21
https://www.youtube.com/watch?v
=31OaRPgmEZc
Appearance of Donor
Site
Healed Skin Grafts
22
Topical Agents
• Silver sulfadiazine(Silvadene) typically used
for acute burns • Topical antibiotic cream
• Antibiotic ointments
• Santyl • Enzymatic debridement ointment that is effective on necrotic
tissue
Topical Agents
Dressings
• To be used to prevent infection, contain
drainage, for pain management
• Types of dressings include:
• Non-adherents such as Adaptic or Xeroform
• Alginates or hydrofibers such as Aquacel Ag
to absorb drainage and prevent infection
• Silicon dressings that gently stick to wound
to protect it but easily comes off without
causing trauma to wound or surrounding skin
− Also useful for scar management
23
Xeroform
Aquacel A
affected
Dressings
Adaptic
Dressings
Mepitel
g
Basic Tenets of Rehab
for the Burn Patient
• Maintenance of function of
areas
• Restoration of physical abilities
• Control of scarring and wound
contractures
• Return to preburn level of functional
activities
• An acceptance of the psychological
impact of a changed self-image and
body image Boswick, 1987
24
Physical Therapist’s Role
• Besides wound care, PTs will be very involved in ensuring patients maintain and/or regain as much function as possible
• Must look out for contractures
• Position of comfort = position of contracture
• Typically a flexed position
• See next slide for proper positioning
• Mobility and strength training important during
recovery
• Respiratory status must also be closely monitored
• Very old video but still relevant: https://www.youtube.com/watch?v=kcQ0LTAeRzk
Proper Positioning Area Affected Position to Prevent Contracture
Anterior neck 10-15 degrees extension
Anterior axilla 90 degrees Shoulder abduction
Posterior axilla Shoulder flexion
Elbow/forearm Extension/forearm neutral
Wrists 15-20 degrees extension
Hands
MCP’s 70-90 degrees flexion
IP’s Full extension
Thumb Palmar abducted and opposed
Palmer
All joints full extension/thumb radially abducted
Hips
Extension, 10 degrees abduction, neutral rotation
Knees Extension
Ankles 90 degrees dorsiflexion
Early Mobilization
• Very important to encourage
OOB and ambulation quickly
after injury
• Even if patient is still on a
ventilator
• Goal is OOB within 24 hours of
admission
25
Exercise • Range of motion:
• Watch for pain at end ranges where
skin is being stretched
• Can be active, active assistive, or
passive
• Strengthening: Needed to avoid loss of
lean body mass
• Cardiovascular: Maintain or improve
function; May be ambulation or even just
a tilt table to avoid orthostatic
hypotension; Avoid overheating the
patient if sweat glands were involved
Range of Motion
Strengthening
26
Splinting
• Use of pre-fabricated and/or custom-
made thermoplastic splint
• When positioning and exercise fail to
treat impairments
• Skin is becoming more inelastic
• Swelling or pressure ulcers are
worsening
• Skin grafting
• Exposed tendon or joint
Schraga et al, Emergent Management of Thermal Burns
Treatment with Splint
• Thermoplastic splints • Low temperature plastic
• Custom made requiring frequent modifications due to dressing changes and/or edema
• Wearing schedule based on:
• Wound status
• Range of motion limitations
• Patient compliance
What can happen if
splinting is not done?
27
of
Splinting
Post Acute Phase
Injury
• Wound Closure until Scar Maturity
• Rehab Goals
• To control hypertrophic scar tissue formation
− Collagen fibers are unorganized and lead to increased
scarring
• To maximize the cosmetic result of the
healed/grafted area
• To decrease the need for and extent of
reconstructive surgery
• To support the patient through his adjustment
to the injury
Principles of
Hypertrophic Scarring
• 1st and superficial 2nd degree burns usually do not scar
• Deep 2nd and 3rd degree burns scar
the most
• Early healing/grafting decreases scarring
• Children scar more than elderly
• Difficult to predict severity of scarring by race of patient
28
Principles of Hypertrophic Scarring
• Clinical signs of hypertrophic
scar formation
• Occurs a few months after injury
• Erythema
• Elevated skin level surface
• Blanching upon stretch
• Stays within area of injury
• If across a joint, can cause
contractures
Principles of
Hypertrophic Scarring
• Stages of Hypertrophic Scarring
• Three R’s vs. Three P’s
Immature: Mature:
-Red -Pale
-Raised -Planar
-Rigid -Pliable
Semi-mature: Pink, raised, Rigid
29
Immature Scars
Mature Scars
Before & After
30
Before & After
Principles of
Hypertrophic Scarring
• Rehabilitation Considerations • Rehab treatment is only effective
on immature and semi-mature scars. A mature scar will not
respond to treatment.
• Hypertrophic scar tissue will
bridge a joint and continue to contract until it meets an opposing
force
Before & After
31
Positive Pressure Therapy
• Treatment of Scars
• Provides constant and controlled pressure
• ~Capillary pressure: 23mm Hg
• Decreases vascularity, which in turn
decreases myofibroblast activity and therefore, collagen synthesis
• Encourages better orientation of collagen
during scarring phase
Positive Pressure
Therapy
• Pressure is applied 24 hours per day for approximately 1 year until the scars are mature
• Begins when the wounds are
healed/closed
• Garment should fit tightly
• Patients should have 2 sets of garments, one to wash and one to
wear
Positive Pressure
Therapy
• Methods of providing pressure: • Ace bandages in the acute phase
• Custom made pressure garments
• Prefabricated pressure garments
• Self-adhesive wraps(Coban, Cowrap)
• Inserts
• Splints
• Transparent Face Masks: Heavy plastic fabricated from a mold or computer scan
of the patient’s face
32
Custom Pressure Garments
Transparent Face Mask
Physical Therapy in the
Post Acute Phase
• Should focus on
• Stretching contracted skin
• ROM of joints
• Swelling
• Strength
• Flexibility
• Sensation
• Function in ADL
• Balance
33
Modalities
• Modalities can used throughout the continuum
of healing for different reasons from wound
healing to pain control and ROM
• Electrical stimulation
• Can be used in open burns to help decrease bacterial load and
increase wound healing
• Ultrasound
• Non-thermal ultrasound helps with collagen synthesis and scar
maturation
• Low-frequency, noncontact ultrasound(MIST therapy) can be
used for wound healing but also assists with scar maturation
• https://www.youtube.com/watch?v=Hb0cKwPUcgw
• Massage
• Compression
Psychosocial Aspects
• Unlike other injuries that are not always
visible to others, most burns are visible
and can cause self-esteem issues in
patients with burns
• Other signs of emotional disturbance
include anxiety, fear, anger, agitation, and
depression (Boswick, 1987)
• Patients with burns often go through
several phases prior truly being able to
accept their injury
Psychosocial Aspects
• Psychological Phases of the Burn patient 1. Critical: Pre-occupation with own somatic
disorders, may experience nightmares and depression
2. Stabilization: More confident of survival, depression persists, anxiety regression more evident, patients are usually more demanding
3. Recovery: Behavior reflects patient’s true personality, patients are more involved in their own treatment and welfare of others
4. Pre-discharge: Ambivalence about discharge, separation anxiety, bouts of depression and euphoria
34
Psychosocial aspects
• Psychological considerations of the burn patient • Fear of death
• Mutilation and disfigurement
• Pain
• Separation from family
• Disruption of lifestyle
• Dependence vs. Independence • Prolonged hospitalization and follow-up
care
• Financial impact of injury
Psychosocial aspects
• Emotional responses to acute injury
• Grieving
• Guilt
• Anger
• Anxiety/fear
• Depression
• Relief to be alive
Psychosocial Aspects
• Guidelines for effective relationships with patients • Set short term achievable goals • Allow the patient to make decisions and
choices when possible • Honor the patient's requests when
legitimate
• Acknowledge the patient's feelings • Encourage discussions of feelings
• Carry out your end of the “contract”
• Use a consistent, positive approach
35
Psychosocial Aspects
• Establish a contract with the
patient
• Purpose: To eliminate
inconsistencies, inequality, and
many of the unfavorable aspects
of being a patient
Conclusion
• Burns are a very specialized aspect of
physical therapy
• Must have a good understanding of the
severity of the burns to be able to guide
your treatment plan
• Mobility and scar management are key
• It is important to have the patient be
highly involved in their care and give
them the ability to set their own goals
and guide their treatment
o_burn_care_A_systematic_review_of_the_literature
36
References • Irion, G. (2010). Comprehensive Wound Management, 2nd edition. Thorofare, NJ:
SLACK Inc.
• Jenkins, J.A., Schraga, E. & Alcock, J. (December 17, 2013). Emergent Management of Thermal Burns. Retrieved January 13, 2014 from
http://emedicine.medscape.com/article/769193-overview#aw2aab6b2
• Lee, K.C., Dretzke, J., Grover, L., Logan, A. & Moiemen, N. (April 27, 2016). A systematic review of objective burn scar measurements. . Retrieved October 4, 2016
from https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-016-0036-x
• Lorello, D.J., Peck, M., Albrecht, M., Richey, Karen J., & Pressman, M.
(September/October 2014). Results of a Prospective Randomized Controlled Trial of Early Ambulation for Patients With Lower Extremity Autografts. Retrieved December
6, 2016 from
http://journals.lww.com/burncareresearch/Abstract/2014/09000/Results_of_a_Prospec tive_Randomized_Controlled.11.aspx
• Mosier, M.J. & Gibran, N.S. (2010). Management of the patient with thermal injuries. Retrieved January 13, 2014 from
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/surgery/div
isions/GITES/burn/Documents/Management%20of%20the%20Patient%20with%20The
rmal%20Injuries.pdf
References • Parry, I., Painting, L., Bagley, A., Kawada, J., Molitor, F., Sen, S., Greenhalgh, D, &
Palmieri, T. (Septmeber/October 2015). A Pilot Prospective Randomized Control Trial Comparing Exercises Using Videogame Therapy to Standard Physical Therapy: 6 Months Follow-Up. Retrieved December 6, 2016 from
http://journals.lww.com/burncareresearch/Abstract/2015/09000/A_Pilot_Prospective
_Randomized_Control_Trial.2.aspx.
• Pontell, M., Sparber, L., & Chamberlain, R. (January/February 2015). Corrective and
Reconstructive Surgery in Patients With Postburn Heterotopic Ossification and
Bony Ankylosis: An Evidence-Based Approach. Retrieved December 6, 2016 from
http://journals.lww.com/burncareresearch/Abstract/2015/01000/Corrective_and_Rec
onstructive_Surgery_in_Patients.8.aspx
• Rowan, M.P., Cancio, L.C., Elster, E.A., Burmeister, D.M., Rose, L.F., Natesan, S.,
Chan, R., & Chung, K. (June 12, 2015). Burn wound healing and treatment: Review and advancements. Retrieved October 4, 2016 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464872/
• RUSH Project funded by the NIDRR completed by: The Rocky Mountain Model
System for Burn Injury Rehabilitation at the University of Colorado Health
Sciences Center. NIDRR Project Number: H133ACB1402. An Easy Guide to
Outpatient Burn Rehabilitation. Last Updated 10/27/2009.
www.researchutilization.org/matrix/resources/burn/burnguide.html
References
• Sheridan, R. & Geibel, J. (2015). Initial Evaluation and Management of the Burn Patient. Retrieved 4 October 2016 from
http://emedicine.medscape.com/article/435402-overview
• Sheridan, R. & Klein, M. (2016). Burn Rehabilitation.
Emedicine.medscape.com. Retrieved 22 September 2016, from
http://emedicine.medscape.com/article/318436-overview#a1
• Sheridan, R. & Meier, R. (2014). Burn Rehabilitation; Psychiatric Aspect of
Recovery. Emedicine.medscape.com. Retrieved 20 April 2016, from
http://emedicine.medscape.com/article/318436-overview#a10
• Szabo, M., Urich, M., Duncan, C., & Aballay, A. (January 2016). Patient adherence to burn care: A systematic review of the literature. Retrieved
December 6, 2016 from https://www.researchgate.net/publication/290480244_Patient_adherence_t